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IJ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Translerable, Revocable, Suspendable) - 4� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL y (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinancg.No. 1862 nd the rules an tions of.the San Joaquin Local Health District. Exact Site Address; Y +i �G City/Tawn Owner's Name Phone Address / City_ Contractor's Name License# Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR® REPLACEMENT13. DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy f Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL u ❑ CABLE TOOLDia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ;; ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information X ❑ GEOPHYSICALI' Surface Seal Installed By: PUMP INSTALLATION: Contractor dpa oqir at a Type of Pump �dt s.l�T_ __ H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ® State Work Done 14-A _Cu ZCZA, Al J a m J2 —."r In DESTRUCTION OF WELL: WeII Diameter Approximate Depth S p Describe Material and Procedure hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:A certify that in the performance of the work for which this permit. is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." IW will all for a Grout Inspection prior to gr In and final 'inspection. `I - Signed X itle: ,�^ � Date: (Draw Plo an on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date Z p Additional Comments: - Phas II Grout Inspection Phase til Final Inspection I Inspection By . ' Date Inspection By Dateou Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE. DATE REMITTED AMOUNT I. FEE , LESS PRORATION s PLUS ' PENALTY OTHER II OTHER AA ON� Received by ii - Date Receipt No. Permit No. Issuanc Date Mailed Delivered -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 952 ,ice